Disorders of the gastrointestinal tract in children: consultation-liaison experience

Disorders of the gastrointestinal tract are common in children. Fortunately, many are short-lived, related to infection, food intolerance, or specific etiology. Those that persist or recur require greater attention on the part of the physician and can require psychiatric consultation. The frequency of consultation will depend in large part on the psychosocial sophistication and philosophy of care of the referring physician. When consulted, the child psychiatrist can complement the medical care by examination in greater detail of the psychosocial environment of the child, the family, and by psychiatric evaluation of the child. Formulation of these factors may then point the way to more helpful management of the child and treatment. The most serious problems, such as regional ileitis and ulcerative colitis, require not only collaboration of pediatricians and child psychiatrist, but surgeons as well if patients are to receive optimum care.

Response of patients to upper gastrointestinal endoscopy: effect of inherent personality traits and premedication with diazepam

The influence of personality traits on the reaction of patients to upper gastrointestinal endoscopy was studied prospectively in 86 patients. High N (neuroticism) scores on the Eysenck personality inventory were associated with poor tolerance to and future compliance with the procedure. Although premedication with diazepam did not affect the degree of discomfort and distress during the procedure, it guaranteed acceptance of repeat endoscopy by virtue of its strong amnesic effect. By contrast, not giving premedication to patients who were anxious and had high N scores jeopardized future compliance. These findings suggest that a version of the Eysenck personality inventory should be used to assess patients' neurotic phenotype and their need for premedication before endoscopy. Alternatively, all patients might be given premedication.

Screening for depression in geriatric medical patients

Depression, a common and treatable psychiatric disorder in later life, is often overlooked in geriatric medical patients. The authors evaluated the validity of two self-rating depression scales, the Zung Self-Rating Depression Scale and the Popoff Index of Depression, for 55 elderly patients. They compared these ratings with the diagnosis assigned by a psychiatrist who was blind to scale results and who interviewed these patients using DSM-III criteria. The two scales correctly classified 80% and 69% of the subjects, respectively. The authors identify six items from the two scales that may serve as a simple screening instrument for the detection of depression in geriatric medical patients.

[Hypnosis in general medicine]

Organic pathologies with psychoaffective aetiology are numerous, and in all diseases, mental and rational elements are concomitant with the organic situation. Aware of the psycho-dynamic mechanisms he sets in motion by his actions and appreciating those underlying the symptomatology he has to deal with, the hypnologist transcends the overspecialisation of medical science to restore the patient's psycho-physical unitary reality. This explains both the possibilities of hypnositherapy in general medicine and its impassable limits. The hypnositherapy that the general practitioner can (and most implement must be perfected by a qualified psychotherapeutist when symptomatology cannot be eradicated without tackling the aetiological factor with a serious analysis of the profound. Hypnosis is, therefore, an extra therapeutic possibility for the physician and this is why it can only be used with science, awareness and on the basis of ethics.

[Diagnosis and therapy of functional gastrointestinal disorders]

Functional gastrointestinal disorders represent a form of non-verbal language limited to humans. They do not always result from a primary psychological disturbance but may be the first symptoms of an organic disease. The functional disorders originating from the oral cavity, the esophagus, the stomach, and the small and large intestines are tabulated.

[Definition of what is accepted as "organic" digestive disease and "functional" digestive disease]

The classification of etiopathogenic factors in organic and functional ones, is not enough precise or clear. Whenever an anatomic or biochemical (metabolic, enzymatic or hormonal) cause exists, the disease is called "organic". Psychologic factors can account for "organic" or "functional" manifestations. A digestive disease is said to be functional, when, in spite of present knowledge, no anatomic or biochemical cause is found, whether or not psychologic factors are present. It would be simpler to adopt the multifactorial etiopathogenic concept multiple possible causes acting alone or in combination to produce the disease, because, in the great majority of digestive diseases, organic, functional and psychologic causes coexist.

[Psychosomatic aspects of expert judgement in gastro-intestinal disease (author's transl)]

Psychosomatic aspects in expert judgement about gastro-intestinal disease are important in regard to 3 particular problems: (1) establishing physical fitness for prison confinement, (2) establishing causal relationships between disease and military service, (3) judging the fitness for work, when annuities are demanded from the state insurance agencies. The point last mentioned is most important nowadays and is discussed therefore in more detail.

Stress-related illnesses and sources of stress: comparing M.D.-Ph.D., M.D., and Ph.D. students

A study was conducted to determine the prevalence and incidence of stress-associated illnesses and to identify possible sources of stress among students enrolled in the M.D.-Ph.D. program of a midwestern university. Specially constructed questionnaires were completed by 45 M.D.-Ph.D. students, 334 M.D. students, and 42 Ph.D. students at this university. The information obtained from the M.D.-Ph.D. students was compared with the responses of the M.D. students and the Ph.D. students. Male M.D.-Ph.D. students had a significantly higher incidence of hypertension, colitis, and asthma, while female M.D.-Ph.D. students reported a higher usage of antacids and occurrence of gastritis or ulcers during the time that they were enrolled in their programs. M.D.-Ph.D. students indicated that the fear of flunking out of school and the grading system were more stressful than did the M.D. students. Additionally, relationship with the graduate adviser and the graduate committee was more stressful to M.D.-Ph.D. students than to Ph.D. students.

Non-organic gastrointestinal illness: a medical and psychiatric study

One hundred consecutive referrals to a general medical out-patient clinic were evaluated psychiatrically under blind conditions in order to investigate the nature and occurrence of non-organic disease presenting as gastrointestinal illness. Twenty-eight patients had marked psychiatric illness with or without physical illness, and there was an association between psychiatric illness and the absence of organic disease, as determined by outcome at follow-up of 4-11 months. Patients with obsessional traits were more at risk of non-organic illness. Historical items indicating a likelihood of non-organic gastrointestinal illness included "nerves", "depression", unhappy childhood, early parental loss and early separations from parents during childhood. Psychiatric illness often persisted after treatment for physical symptoms. Some of the techniques used in this study to identify psychiatric illness could be usefully employed in everyday practice.

Cognition and the disease process: genesis, maintenance, and treatment

The present paper is directed toward the conceptualization of disease states and their management from the cognitive point of view. The role of cognitive sytlesand self-statements in the pathogenesis of disease and the execution of coping styles is presented. A review of the literature on the cognitive treatment of medical disorders has documented the utility of such approaches with several medical problems, but a need for more rigorous empirical efficacy remains. The necessity of analyzing the coping processes elicited by specific disease states is viewed as essential to the understanding of the patient and the design of intervention strategies. Finally, a cognitive analysis of patient compliance to treatment regimens is presented.

[Impairment of driving ability by infections of the gastrointestinal region (author's transl)]

Experience shows that infections in the region of the gastrointestinal tract are apparently not very common causes of traffic accidents. In particular, impairment by the disease itself including treatment with its effects and side effects must be considered. Also the patient's own assessment of his condition is extremely meaningful and must not be disregarded at the consultation. Furthermore the length and circumstances of the journey and consideration of the age of the patient and other disease conditions are important.

Alexithymic feature in digestive diseases

A comparative study was conducted on the psychological features of chronic pancreatitis, peptic ulcer, ulcerative colitis and the irritable colon syndrome by means of psychological tests and interviews. The patients with irritable colon syndrome were found to be the most neurotic of all, whereas those with the definite type of chronic pancreatitis and ulcerative colitis presented prominent alexithymic characteristics. About one half of the patients having peptic ulcer showed alexithymic features. Despite their neurotic tendencies shown on the psychological tests, the patients with the suspicious type of chronic pancreatitis were socially better adjusted than those with irritable colon syndrome. It was also noted that the concept of alexithymia needs to be elucidated by including such factors as over-adaptation to the environment, certain distorted life habits and lack of bodily sensations.

Physical illness presenting as psychiatric disease

A study of 658 consecutive psychiatric outpatients receiving careful medical and biochemical evaluation, defined an incidence of medical disorders productive of psychiatric symptoms in 9.1% of cases. The most frequent presentations were of depression, confusion, anxiety, and speech or memory disorders. The presence of visual hallucinations was believed to indicate medical etiology until proved otherwise. Major illnesses presenting with psychiatric symptoms in order of frequency were infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic and CNS diseases. Forty-six percent of these patients suffered from medical illnesses previously unknown to either them or their physician. A plea is made for careful medical evaluation of psychiatric patients.